Reimbursement Form

Instructions:

1. Fill out completely with description of reimbursement and breakdown of expenses by budget category (missing info will delay payment).

2. Attach file(s) with copies of all receipts, preferably a PDF. Multiple receipts within a single file are allowed.

3. Specify how to deliver payment. A check can be mailed, or it can be left in a mailbox or the PTA drawer in the staff room.

4. Leave blank the "approval" and "check" fields at the bottom

Note: A receipt of your submitted request will be automatically emailed to your address in your profile

Reimbursement Information

Total Amount For Reimbursement:

Payment Payable To (Name):

Choose Payment Method*

Provide street address for mailed checks, or any other payment delivery information

Expense 1 - Amount

Expense 1: Account to Be Charged

Expense 1 Is For:

Expense 2 - Amount

Expense 2: Account to Be Charged

Expense 2 Is For:

Expense 3 - Amount

Expense 3: Account to Be Charged

Expense 3 Is For:

Attach Receipt 1

Attach Receipt 2

Attach Receipt 3

Approved By

Approval Date:

(to be completed by the Treasurer)

Date Check Issued

Check Number:

Notes